pengkajian keluarga 2015
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FORMAT PENGKAJIAN KELUARGA
PRAKTEK KEPERAWATAN KELUARGA MAHASISWA PRODI DIII
KEPERAWATAN BENGKULU JURUSAN KEPERAWATAN POLTEKKES
KEMENKES BENGKULU
TA. 2014/2015
I. DATA UMUM
1. Nama Kepala Keluarga : ........................................................................................
2. Alamat dan telepon : ........................................................................................
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3. Pekerjaan kepala keluarga : ........................................................................................
4. Pendidikan Kepala Keluarga : ........................................................................................
5. Komposisi Keluarga : ........................................................................................
No Nama JK
Hubungan
Dgn Kepala
Keluarga
Umur Pnddk Status Imunisasi KET
BCG Polio DPT Hepatitis Campak
1 2 3 4 1 2 3 1 2 3
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Genogram (tiga generasi) :
6. Tipe Keluarga : ........................................................................................
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7. Suku Bangsa : ........................................................................................
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8. Agama : ........................................................................................
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9. Status Sosial Ekonomi : ........................................................................................
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10. Aktifitas Rekreasi Keluarga : ........................................................................................
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II. RIWAYAT TAHAP PERKEMBANGAN KELUARGA
11. Tahap Perkembangan Keluarga saat ini :
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12. Tahap Perkembangan Keluarga yang belum Terpenuhi :
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13. Riwayat Keluarga Inti :
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14. Riwayat keluarga sebelumnya :
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III. LINGKUNGAN
15. Karakteristik Rumah :
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Denah Rumah :
16. Karakteristik tetangga dan Komunitas RW :
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17. Mobilitas Geografis Keluarga :
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18. Perkumpulan Keluarga dan Interaksi dengan masyarakat :
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19. Sistem Pendukung Keluarga :
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IV. STRTUKTUR KELUARGA
20. Pola Komunikasi Keluarga :
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21. Struktur Kekuatan Keluarga :
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22. Struktur Peran Formal dan Informal :
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23. Nilai dan Norma dalam Keluarga :
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V. FUNGSI KELUARGA
24. Fungsi Afektif :
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25. Fungsi Sosial
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26. Fungsi Perawatan Keluarga :
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27. Fungsi Reproduksi :
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28. Fungsi Ekonomi :
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VI. STRES DAN KOPING KELUARGA
29. Stresor jangka pendek dan Panjang :
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30. Kemampuan keluarga Berespon terhadap situasi / stresor :
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31. Strategi Koping yang Digunakan :
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32. Strategi Adaptasi Disfungsional
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VII.PEMERIKSAAN FISIK ( HEAD TO TOE ) ( Dikaji pada setiap anggota keluarga )
NO VARIABEL NAMA ANGGOTA KELUARGA
Tn. Ny. An. An.
1 Riwayat penyakit saat
ini
2 Keluhan yang
dirasakan
3 Riwayat penyakit
sebelumnya
4 Tanda-tanda vital
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5 Kepala
6 Leher
7 Thoraks
8 Abdomen
9 Esktremitas
10 Kulit
11 Genetalia
VIII. HARAPAN KELUARGA
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IX. ANALISIS DATA
No DATA ETIOLOGI MASALAH
Data Subjektif :
Data Objektif :
Data Subjektif :
Data Objektif :
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Data Subjektif :
Data Objektif :
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X. PRIORITAS MASALAH
DX. I .
…………………………………………………………………………………………….
No Kriteria Skor Bobot Pembenaran
1 Sifat Masalah
Skala : Tidak / Kurang Sehat
Ancaman Kesehatan
Keadaaan Sejahtera
3
2
1
1
2 Kemungkinan Masalah dapat diubah
Skala : Mudah
Sebagian
Tidak dapat
2
1
0
2
3 Potensial Masalah Untuk dicegah
Skala : Tinggi
Cukup
Rendah
3
2
1
1
4 Menonjolnya Masalah
Skala : Masalah Berat harus segera di tangani
Adanya Masalah tetapi tidak perlu ditangani
Masalah Tidak Dirasakan :
2
1
0
1
Jumlah
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Dx 2. .
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No Kriteria Skor Bobot Pembenaran
1 Sifat Masalah
Skala : Tidak / Kurang Sehat
Ancaman Kesehatan
Keadaaan Sejahtera
3
2
1
1
2 Kemungkinan Masalah dapat diubah
Skala : Mudah
Sebagian
Tidak dapat
2
1
0
2
3 Potensial Masalah Untuk dicegah
Skala : Tinggi
Cukup
Rendah
3
2
1
1
4 Menonjolnya Masalah
Skala : Masalah Berat harus segera di tangani
Adanya Masalah tetapi tidak perlu ditangani
Masalah Tidak Dirasakan :
2
1
0
1
Jumlah
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XI. DIAGNOSA KEPERAWATAN SESUAI PRIORITAS
1. …………………………………………………………………………………………
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2. …………………………………………………………………………………………
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3. …………………………………………………………………………………………
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4. …………………………………………………………………………………………
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XII. RENCANA ASUHAN KEPERAWATAN KELUARGA
No Diagnosa Keperawatan Tujuan Kriteria Evaluasi Rencana Intervensi
Tjuan Umum
Tujuan Khusus
Kriteria Standar
NB : Rencana dibuat untuk kelima tujuan sesuai tugas keluarga
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XIII. PELAKSANAAN DAN EVALUASI
No Tanggal Diagnosis
Keperawatan
Keluarga
Tujuan Khusus Implementasi Evaluasi
S
O
A
P
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